Job Description

Job Description

Job Description

ABOUT THE ORGANIZATION

Community Health Programs is a network of health centers and caring professionals that provide outstanding primary and preventive care for patients of all ages. What's truly unique to CHP is our broad spectrum of support services that extend beyond medical and dental issues to strengthen families and improve children's well-being. The region is a federally designated rural community and a Medically Underserved Population Area.

Community Health Programs embraces its role as a nonprofit health care provider and community partner. We are a leader in the communities we serve by providing high quality healthcare, dental services, wellness education and family support services. CHP outreach provides free health screenings, insurance enrollment assistance as well as information so people can learn how to take better care of themselves and their families.

Salary Range: $70,000 - $90,000 / year Summary: The Nurse Case Manager (NCM) conducts comprehensive patient assessments to manage healthcare needs across the care continuum. This role aims to enhance individual health and self-management skills through a multidisciplinary team, including behavioral health and community health workers. Key responsibilities include performing in-office or hospital face-to-face visits for members requiring such interactions and assessments. The goal is to coordinate and facilitate services that meet member needs in accordance with benefit structures and available community resources. The NCM, alongside the interdisciplinary team, will develop patient care plans in collaboration with the patient, ensuring cost-effective and quality outcomes focused on the ambulatory setting. Embedded within provider offices, the NCM works closely with providers, office staff, care management staff, and community partners to manage member care. This person will support CHP’s mission, vision, and values and will adhere to compliance protocols as well as CHP’s policies and procedures.

POSITION REQUIREMENTS

Nurse Case Manager Essential Duties and Responsibilities:

• Assesses and case manages a member panel.
• May conduct face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques to:
  1. assess a member’s clinical/functional status to identify ongoing special conditions and
  2. develop and implement an individualized, coordinated care plan, in collaboration with the member, the clinical team, and primary care providers, specialist and other community partners, to ensure a cost-effective quality outcome.
• Performs medication reconciliations.
• Performs Transitional Care Management (TCM) – per program and product line processes.
• Stay informed about program and product line benefits, Plan Handbook details, and department policies. Follow outlined procedures to educate members and providers, advocating for member rights and providing necessary education.
• Advocate for members to ensure they receive appropriate Fallon Health benefits. If member needs are identified and they are not Fallon eligible, collaborate with community agencies to connect members with additional services, such as transportation, food programs, and senior center resources, when needs are not covered by Fallon Health.
• Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives.
• Assesses the member’s knowledge about the management of current disease processes and medication regimen, provides teaching to increase member/caregiver knowledge, and works with the members to assist with learning how to self-manage his or her health needs, social needs or behavioral health needs.
• Collaborates with appropriate team members to ensure health education/disease management information is provided as identified.
• Collaborates with the interdisciplinary team in identifying and addressing rising and high-risk members.
• Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes.
• Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team.
• Strictly observes HIPAA regulations and the CHP policies regarding confidentiality of member information.
• Supports Quality and Ad-Hoc campaigns.

• Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives.
• With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the member to approve their care plan.
• Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the member’s health care goals and needs.
• Build and maintain relationships with members, family, caregivers, PRAs, vendors, and providers to ensure optimal collaboration and coordination of healthcare needs, promoting timely, cost-effective, and high-quality care.
• Actively participates in clinical rounds.
• May coordinate and/or attend in person member/provider visits, care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable.
• Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met.
• Performs other responsibilities as assigned by the Manager/designee.

• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee.
• Identify high risk patients by reviewing the monthly risk stratification data.

Competencies: To perform the job successfully, an individual should demonstrate the following competencies:

• Excellent communication and interpersonal skills with members and providers via telephone and in person.
• Exceptional customer service skills and willingness to assist in ensuring timely resolution.
• Excellent organizational skills and ability to multi-task.
• Appreciation and adherence to policy and process requirements.
• Independent learning skills and success with various learning methodologies.
• Willingness to learn insurance regulatory and accreditation requirements.
• Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word.
• Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables.
• Accurate and timely data entry.
• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need.
• Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria.

Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Experience:

• 2+ years of clinical experience as a Registered Nurse working with ages across the lifespan.
• Experience working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions preferred.
• Understanding of hospitalization experiences and the impacts and needs after facility discharge required.
• Ability to communicate and collaborate with PCP, community and ACO partners to manage members care required.
• Experience with telephonic interviewing skills and working with a diverse population, which may also be non-English speaking, required.
• Home Health Care experience preferred.
• Experience working in a community social service agency, skilled home health care agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred.
• Experience working face to face with members and providers preferred.
• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need working in partnership with a care team preferred.
• Demonstrated ability to perform independently as a clinician with minimal supervision or assistance.

• Experience with self-scheduling of caseload preferred.

Education and Training:

• Registered Nurse required.
• Bachelors (or advanced) degree in nursing or a health care related field preferred.
• Graduate of a N.L.N. accredited nursing program.
• CPR is required every two years.

License, Certification C. & Registration:

• RN - License as a professional nurse within MA.
• Active and valid driver’s license.

Physical Requirements:

• Click here to view the Administrative ADA requirements

FULL-TIME/PART-TIME Full-Time

POSITION ACO Nurse Case Manager

EXEMPT/NON-EXEMPT Exempt

LOCATION MA, Pittsfield, CHP Neighborhood Health Center

EOE STATEMENT

We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.

PI250a8a473362-25405-37062076

Job Tags

Full time, Part time,

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